Diabetic Foot Ulcers And The Use Of low Level Laser Therapy(LLLT) or Photobiomodulation
Diabetes is a wide spread medical condition which is associated with a wide range of complications. Foot ulcers are one of such complication. The chance of development of foot ulcers in diabetic patients could be as high as 25%. (1) These diabetic foot ulcers can become persistently non healing ulcers, which can sometimes only be managed by amputation of the affected leg. It has been shown that the longer the ulcer persists, the greater are the chances that a serious infection will develop that may lead to hospitalization or even amputation(2). Previous research have shown that over 70% of non traumatic lower limb amputations were done in diabetic patients, that resulted in high morbidity and mortality (3). In addition to diminishing the quality of life of the patient and increased cost of care, they are more likely to die within next 5 years of amputation as compared to those diabetic patients who do not undergo amputation (4).
Cause of Diabetic Foot Ulcers:
The evident causes of foot ulceration in diabetic people are due to the peripheral neuropathy and ischemia. Neuropathy causes impaired vascular circulation and loss of sensations. (5) This leads to decreased pain sensations which lead to neglect of small cuts and bruises, which then grow as a result of impaired vascular circulation. The impaired vascular circulation decreases the rate of wound repair by decreasing the release of growth factors, the number of macrophages in the wound, and impaired leukocyte functions. (6)
Management of Diabetic Foot Ulcers:
A number of traditional treatment modalities include application of different types of dressings, offloading, debridement or managing by revascularization surgeries. The International Working Group the Diabetic Foot suggested that medical management such as negative pressure wound therapy (7) (8), hyperbaric oxygen therapy and offloading that could relieve the plantar pressure (8) may be beneficial for healing of the ulcer wound. However, a number of diabetic foot ulcers may not heal by these treatment methods. An important factor to consider for the management of diabetic ulcer is the proper classification if the diabetic foot ulcers. The most widely accepted and universally used grading systems include the Wagner – Meggitt system (9) and the University of Texas Diabetic Wound Classification System (10)
Some information on diabetic foot wound care
Low Level Laser Therapy in management of Diabetic Foot Ulcers:
Electro physical therapy (EPT) has been in use in physiotherapeutic management of diseases for quite some time now. The different modalities range from use of sound waves (ultrasound) and light (Laser) to electromagnetic energy. High powered non-invasive Laser therapy has been shown to promote angiogenesis (11), enhance fibroblast activity, (12) and promote tissue repair. It has been reported as a noninvasive procedure which could be used to encourage chronic wound healing. Non-invasive and non- thermal Low Level Llaser therapy uses low irradiation intensities and exerts its biologic effects by direct effects of radiation of the photons. (13).This has been shown to positively affect the wound healing by the release of the growth factors locally (14), and increased production of collagen and proliferation of fibroblasts. (15)(16).Additionally Laser therapy has been found to increase the microcirculation of the skin significantly as well. (15)
Wound care via Laser therapy
Research on non-invasive LLLT as an effective modality in management of Diabetic Foot Ulcers:
Previous researches have shown that there was a significant improvement in the healing rate and ulcer granulation of the tissue when laser light was used for the management of diabetic foot ulcer. (20) Animal studies have also shown that lasers enhance tissue repair in diabetic ulcers. It has also been shown to completely heal the ulcer as well as reduce the size of the ulcer. (21) A significant positive effect of non-invasive LLLT has been the improvement of nerve conduction velocity on diabetic distal symmetric neuropathy. (22) This means that LLLT or photomodulation can be of use in prevention of development of diabetic ulcers altogether. Such results have drawn the attention of physicians tending to diabetes.
Mechanism of Action of LLLT:
To study the effects of laser on the wound healing, research has been done at three levels: cellular function, animal studies and clinical trials. (14) Cellular function experiments have provided both theoretical and experimental proof of the beneficial effects of the laser on wound healing. These studies showed an increase in the proliferation of fibroblasts which assists in the repair phase of tissue healing. (16)(17) Similar beneficial effects are seen in animal studies. (14) An increase in the cytokines as a result of the raised temperature of the tissues at the site laser irradiation has also been postulated as a mechanism of action of laser in improving the repair process. (15) The mechanism of action by which LLLT improves the diabetic neuropathy as shown by improved Nerve Conduction Velocities, is still being investigated. Various methods have been suggested such as improvement in the function of damaged neurological tissue (18) and reduction in inflammation. (19) This improvement in diabetic neuropathy can help to prevent as well as treat the diabetic foot ulcers in the early stages.
LLLT mechanism of action
The current research work provides proof that non-invasive LLLT can be an effective tool in the management of non healing foot ulcers in patients with diabetes. The improved microcirculation associated with the management of diabetic foot ulcer with this type of laser therapy provides reasonable rationale for its continued use in patients suffering from this complication. (23) The improvement seen in the neuropathy associated with diabetic foot suggests laser therapy can and should be used for the management of pain symptoms of polyneuropathy. (22) The absence of side effects also furthers the promotion of high powered non-invasive laser therapy as an effective modality for the treatment of these ulcers. (23) Such results prove that there is still hope for the cure and even prevention of development of diabetic foot ulcers. The research to develop a standard guideline for the use of such laser therapy should be continued and promoted so that a larger number of diabetic patients can benefit from laser therapy.
2. 1999–2000 National health and nutrition examination survey. Gregg, E.W., Sorlie, P., Paulose-Ram, R., et al. 2004, Diabetes Care, Vol. 27, pp. 1591-1597.
3. Incidence of lower limb amputations and diabetes. Trautner C, Haastert B, Giani G, Berger M. 1996, Diabetes Care, Vol. 19, pp. 1006-9.
4. Quality of life in patients with diabetic foot ulcers. Meijer, J.W., Links, T.P., Smit, A.J., Groothoff, J.W., and Eisma, W.H. 2001, Disabil. Rehabil, Vol. 23, pp. 336-340.
5. Evidence-based protocol for diabetic foot ulcers. Brem H, Sheehan P, Rosenberg HJ, Schneider JS, Boulton AJ. 2006, Plast Reconstr Surg, Vol. 117, pp. 193S-211S.
6. Interactions of cytokines, growth factors, and proteases in acute and chronic wounds. Mast, B.A., and Schultz, G.S. 1996, Wound Repair Regen, Vol. 4, pp. 411-420.
7. A systematic review of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Game FL, Hinchliffe RJ, Apelqvist J, Armstrong DG, Bakker K,Hartemann A, Londahl M, Price PE, Jeffocate. 2012, Diabetes Metab Res Rev, Vol. 28, pp. 119-41.
8. The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review. Bus SA, Valk GD, van Deursen RW, Armstrong DG, Caravaggi C,Hlavacek P, Bakker K, Cavanagh PR. 2008, Diabetes Metab Res Rev, Vol. 24, pp. S162-80.
9. Structural changes in the forefoot of individuals with diabetes and a prior plantar ulcer. Robertson DD, Mueller MJ, Smith KE, Commean PK, Pilgram T, Johnson JE. 2002, Jo Bone Joint Surg Am, Vol. 84, pp. 1395-404.
10. Validation of a diabetic wound classification system: the contribution of depth, infection, and ischemia to risk of amputation. Armstrong DG, Lavery LA, Vela SA, Quebedeaux TL, Fleischli JG. 1998, Diabetes Care, Vol. 21, pp. 855-9.
11. Electrotherapy promotes healing and microcirculation of infrapopliteal ischemic wounds: a prospective piot study. Goldman R, Rosen M, Brewley B, Golden M. 2004, Adv Skin Wound Care, Vol. 17, pp. 284-94.
12. The effect of 880nm low level laser energy on human fibroblast cell numbers: a possible role in hypertrophic wound healing. Webb C, Dyson M. 2003, J Photochem Photobiol B, Vol. 70, pp. 39-44.
13. Effects of lasers on wound healing. Mester, E., Spiry, T., Szende, B., and Jolan, T. 1971, Am J Surg, Vol. 122, pp. 532-535.
14. Low-level laser therapy for wound healing: mechanism and efficacy. Posten, W., Wrone, D.A., Dover, J.S., Arndt, K.A., Silapunt, S.,and Alam, M. 2005, Dermatol. Surg, Vol. 31, pp. 334-340.
15. Systemic effects of low intensity laser irradiation on skin microcirculation in patients with diabetic microangiopathy. Schindl, A., Heinze, G., Schindl, M., Pernerstorfer-Schon, H. and Schindl, L. 2002, Microvasc. Res, Vol. 64, pp. 240-246.
16. Effectiveness of helium-neon laser irradiation on viability and cytotoxicity of diabetic-wounded fibroblast cells. Houreld, N.N., and Abrahamse, H. 2007, Photomed. Laser Surg., Vol. 25, pp. 474-481.
17. Low-level laser therapy increases transforming growth factor-beta2 expression and induces apoptosis of epithelial cells during the tissue repair process. Rocha Ju´ nior, A.M., Vieira, B.J., de Andrade, L.C., and Aarestrup, F.M. 2009, Photomed. Laser Surg, Vol. 27, pp. 303-317.
18. low-level laser therapy applied transcranially to mice following traumatic brain injury significantly reduces long-term neurological deficits. Oron A, Oron U, Streeter J, de Taboada L, Alexandrovich A, Trembovler V, Shohami E. 2007, J Neurotrauma, Vol. 24, pp. 651-6.
19. Biphasic Dose Response in Low Level Light Therapy. Huang YY, Chen AC, Carroll JD, Hamblin MR. 2009, Dose-Response, Vol. 7, pp. 358-383.
20. Phototherapy promotes healing of chronic diabetic leg ulcers that failed to respond to other therapies. Minatel DG, Frade MAC, Franca SC, Enwemeka CS. 2009, Lasers Surg Med, Vol. 41, pp. 433-41.
21. A randomized clinical trial on the effect of low-level laser therapy on chronic diabetic foot wound healing: a preliminary report. Kaviani AK, Djavid GE, Ataie-Fashtami L, Fateh M, Ghodsi M, Salami M, Zand N, Kashef N, Larijani B. 2011, Photomed Laser Surg, Vol. 29, pp. 109-14.
22. Diabetic distal symeetric polyneuropathy: Effect of low-intensity laser therapy. Khamseh ME, Kazemikho N, Aghili R, Forough B, Lajevardi M, Hashem Dabaghian F, Goushegir A, Malek M. 2011, Lasers Med Sci, Vol. 26, pp. 831-5.
23. Low-intensity laser irradiation improves skin circulation in patients with diabetic microangiopathy. Schindl A, Schindl M, Schön H, Knobler R, Havelec L, Schindl L. 1998, Diabetes Care, Vol. 21, pp. 580-4.